HEC-C Preparation Guide: Ethical Assessment, Consultation, and Improvement Study Guide

Apply it

A handoff calls a daughter obstructive, but the nurse reports that she requested an interpreter before discussing surgery. Record both accounts, establish the sequence, and clarify whether any informed refusal actually occurred before analyzing disagreement.

Apply it

Relatives disagree about continued ventilation. Before framing the conflict as incompatible values, the consultant asks whether clinicians disagree about expected recovery, which outcomes remain possible, and when additional observations might meaningfully reduce that uncertainty for everyone.

Apply it

A son requests every available treatment because he wants his mother to recognize visiting grandchildren. The consultant clarifies that desired outcome with him and asks clinicians which interventions could plausibly support it and at what burdens.

Apply it

A patient declines recommended treatment and accurately explains its purpose, likely consequences, alternatives, and personal reasons for refusal. The consultant asks the team to assess those abilities directly instead of using refusal itself as proof of incapacity.

Apply it

During a video visit, a patient gives unrelated answers because captions are unavailable and speech is difficult to hear. The consultant recommends an accessible communication arrangement, followed by reassessment of understanding before anyone shifts decision authority.

Apply it

An unmarried partner knows the patient's wishes, while a sibling claims automatic authority. The consultant checks for a designated agent and the applicable selection framework, while ensuring that the partner's relevant knowledge is heard during deliberation.

Apply it

At a family meeting, one sibling answers every question while another repeatedly starts and stops speaking. The consultant offers individual opportunities to explain concerns, then brings the relevant perspectives into a shared discussion without ranking relatives by assertiveness.

Apply it

A patient requests family involvement before accepting surgery. Instead of attributing the request to a presumed cultural rule, the consultant asks whom the patient wants involved, what their role should be, and whether the patient retains the final choice.

Apply it

A spouse repeatedly asks the same prognosis question after receiving devastating news. The consultant acknowledges the loss, checks what was understood, and identifies the pending treatment choice before concluding that the spouse rejects the medical information.

Apply it

A patient misses repeated follow-up visits and is described as uninterested in care. An interview reveals that appointments conflict with the only available transport. The consultant identifies an access problem before the team judges the patient's commitment.

Apply it

A patient is offered an unfamiliar procedure during a study visit. The consultant asks which components are individualized care, which collect information for the study, and whether the patient understands that distinction before analyzing the consent process.

Apply it

Relatives ask clinicians not to disclose a diagnosis because they expect distress. The consultant first asks the patient how medical information should be shared and whether anyone should receive information on the patient's behalf before endorsing secrecy.

Apply it

A patient agrees to share records with the treating team but objects to an educational observer during an intimate examination. The consultant distinguishes informational access for care from permission for the observer's physical presence and supports a separate permission discussion.

Apply it

A referral asks ethics to solve a delayed discharge. The consultant discovers that the disagreement concerns whether the proposed placement respects the patient's expressed priorities despite safety concerns, then frames that decision explicitly for the involved parties.

Apply it

A daughter insists on hospital transfer, while staff favor care in the current facility. Asked about her concern, she describes fear of untreated pain. The consultant checks whether reliable symptom management could address that concern within either setting.

Apply it

A consultant assumes that a family requesting continued treatment has misunderstood prognosis. Before proceeding, the consultant asks what the family understands and learns that its disagreement concerns acceptable burdens, not the predicted outcome of treatment itself.

Apply it

A clinician says hospital policy requires treatment whenever relatives disagree. The consultant requests the actual policy, checks its scope and decision process, and identifies whether the reported requirement is written policy, local practice, or a mistaken recollection.

Apply it

A patient signs a procedure form but believes the intervention is guaranteed to work. The consultant identifies a gap in understanding and recommends clarification of expected benefits, uncertainty, alternatives, and refusal before treating the signature as sufficient consent.

Apply it

An unconscious patient needs immediate treatment, and staff cannot reach a surrogate in time. The consultant distinguishes care needed during the emergency from subsequent decisions that should return to an informed consent process once participation or surrogate contact becomes possible.

Apply it

A son prefers continued treatment but recalls his father's repeated statements rejecting prolonged dependence under the circumstances now described by clinicians. The consultant helps him evaluate the treatment through his father's values rather than through his own understandable wish.

Apply it

An incapacitated patient has no available history of treatment preferences. The consultant helps the authorized decision maker compare expected benefit and burden for each option, while separating the patient's welfare from assumptions about the value of dependent living.

Apply it

A patient with capacity requests treatment that an older directive appears to refuse. The consultant confirms the present informed preference and helps the team document it, rather than allowing the older document to displace the patient's current decision.

Apply it

A team would not recommend starting an intervention today but feels unable to stop it because it began during an emergency. The consultant examines the current goals, burdens, and authorized preferences using the same ethical criteria for continuation.

Apply it

A patient with a DNAR order develops an infection. The consultant asks the team to evaluate antibiotics through the patient's treatment goals and wishes, rather than inferring that the resuscitation order settles whether the infection should be treated.

Apply it

Relatives request an intervention clinicians judge unable to achieve its intended clinical benefit. The consultant clarifies the goal and evidence, corrects misunderstandings, and helps negotiate alternatives. If disagreement continues, the consultant explains institutional review and appeal, supports transfer efforts if unresolved, and ensures a continuing care plan. If no willing receiving clinician or institution is found, that failure alone does not ethically require the intervention.

Apply it

A team and surrogate agree to a treatment trial but have no review plan. The consultant helps specify the reassessment date, meaningful signs of response, patient priorities, and how continued treatment, comfort-focused care, or extension will be considered.

Apply it

A physician invokes conscience to avoid honoring a patient's informed refusal of life-sustaining treatment. The consultant identifies that refusal-related professional duty directly and examines a continuity plan that protects the patient's choice without harmful delay or abandonment.

Apply it

Two patients are judged equivalent under the institution's medically relevant criteria for one scarce resource. An administrator favors a prominent donor. The consultant recommends the established transparent tie-breaking mechanism and explains why prominence is irrelevant to eligibility.

Apply it

A child resists an intervention that can safely be deferred. The team explores the reason, adjusts communication and support, and allows further discussion rather than treating parental permission as sufficient reason to override dissent. If immediate intervention instead becomes essential to prevent serious, irreversible harm, the ethical exception supports proceeding despite refusal to assent, with appropriate explanation and support.

Apply it

A study recruits people from a dependent population because they are easy to reach, while the expected benefits mainly concern others. The consultant examines selection fairness, voluntariness, and risk justification rather than accepting scientific usefulness as sufficient protection.

Apply it

A patient believes enrollment guarantees the treatment the physician thinks is best. The consultant recommends a clear explanation of study assignment and uncertain personal benefit, followed by a check of the patient's understanding before enrollment proceeds further.

Apply it

Clarify whether continued treatment may override an adult's refusal. Assemble evidence that the patient understands and appreciates the consequences, reasons about alternatives, communicates a voluntary choice, and has received relevant disclosure. Synthesize treatment over objection against honoring refusal with supportive care: expected medical benefit supports offering treatment, while the informed refusal weighs against imposing it. Explain why honoring refusal is recommended and why abandonment is excluded. Support communication, appropriate orders by responsible clinicians, symptom care, and follow-up. If new evidence instead establishes that the patient cannot appreciate the consequences, reassess and support decision abilities; if capacity remains absent, identify the appropriate surrogate and decision standard before relying on the refusal as an autonomous authorization.

Apply it

For a patient's informed refusal, principlism identifies tension between respecting choice and offering benefit. Consequentialist analysis compares survival, treatment burdens, distress, and effects on trust. Virtue ethics asks how clinicians can be candid and compassionate without abandoning the patient. Casuistry distinguishes a refusal with capacity from a precedent involving incapacity. Narrative inquiry explores why the patient's life commitments make the burden unacceptable. Feminist inquiry checks whether dependency or pressure prevents a free choice and whose account has been excluded. These inquiries can support honoring refusal with continued care while revealing facts that require reassessment.

Apply it

Staff feel distressed by a patient's informed refusal and ask ethics to require treatment. The consultant examines the refusal process, identifies acceptable care plans that honor the decision, and addresses staff support without treating distress as authority to override.

Apply it

A clinician introduces the consultant as the person who will decide whether treatment stops. The consultant clarifies the advisory role, identifies the responsible decision makers, and explains how ethical reasoning and facilitation can support their work in the case.

Apply it

A clinician requests quick hallway advice about a disputed surrogate decision with immediate treatment consequences. The consultant recognizes that a one-sided account is insufficient and arranges a timely formal assessment rather than issuing a definitive recommendation from that account.

Apply it

A meeting is scheduled with physicians and an adult child, but the patient wants a longtime friend present and needs communication assistance. The consultant adjusts participation and access arrangements before the meeting so the patient's perspective can be represented.

Apply it

A patient says a further group meeting would be overwhelming and declines to attend. The consultant offers an optional individual conversation, respects the refusal, and avoids reporting the patient's absence as consent to the recommendation ultimately discussed by others.

Apply it

A meeting starts with competing accusations about prior conversations. The consultant restates the pending decision, invites each account of the relevant facts, and proposes an orderly discussion of options after identifying points that still require verification from the team.

Apply it

After prognosis is discussed, a surrogate says everything is clear. The consultant asks how the surrogate would explain the options to another relative, discovers an expectation of guaranteed recovery, and invites the clinician to clarify that specific misunderstanding.

Apply it

Two reasonable care plans differ in likely burden and convenience. The consultant helps the patient identify which tradeoffs matter, then asks the clinician to explain how each plan fits those priorities before the patient makes an informed choice.

Apply it

A relative raises their voice after hearing that clinicians disagree with a treatment request. The consultant acknowledges the fear of abandonment, clarifies what care will continue, and then returns to the disputed intervention and its expected benefits and burdens.

Apply it

Everyone at a meeting agrees to follow the loudest relative's preference, although a valid designated surrogate was not invited. The consultant questions the apparent consensus and restores the authority and participation issues before endorsing the proposed treatment plan.

Apply it

A family member offers information about the patient's values only if it will never be mentioned. The consultant clarifies confidentiality limits before hearing details and explores whether relevant information can be shared in a way the person finds acceptable.

Apply it

A consultant is asked to evaluate a policy they authored after staff allege it harmed patients. The consultant discloses that involvement and arranges independent participation in the review so the concern receives scrutiny beyond the author's own defense.

Apply it

A draft note says that the family meeting was productive and treatment should continue. The consultant adds the patient's decision standard, relevant values, reasons supporting the plan, unresolved uncertainty, and the planned reassessment so others can understand and evaluate it.

Apply it

A consultation supports a revised care goal, but bedside staff receive no explanation and existing orders remain unchanged. The consultant coordinates communication with the responsible clinician and identifies who will reconcile the clinical plan and explain it to the patient.

Apply it

A family requests continued intensive treatment partly because severe symptoms appear uncontrolled and spiritual concerns remain unheard. The consultant coordinates appropriate symptom and spiritual support while continuing to analyze the treatment decision and the patient's known values with the participants.

Apply it

A consultation reaches a defensible plan, but a promised communication with an absent surrogate remains unfinished. The consultant assigns and confirms that follow-up, documents the remaining contingency, and explains when renewed consultation would be useful if the situation changes.

Apply it

A consultation reveals that different units apply conflicting procedures for identifying surrogates. The consultant resolves the immediate authority question through the applicable framework and sends the broader inconsistency to the responsible policy group for coordinated review and possible revision.

Apply it

A case ends with agreement, but peer review finds that the patient's own perspective was never sought despite feasible participation. The consultant changes the preparation process and later checks whether patient involvement improves across subsequent consultations in similar circumstances.

Apply it

Only clinicians return a consultation survey, and all report satisfaction. The evaluator records the missing patient and family responses, examines whether the survey was accessible, and avoids describing the results as proof that all participants found the consultation helpful.

Apply it

One consultant records hallway advice and another records only formal meetings. Before comparing their volumes or issue patterns, the service agrees on inclusion and coding definitions, reviews recording completeness, and marks when the shared definitions take effect in reports.

Apply it

A service introduces a structured meeting summary. It tracks whether summaries are completed and whether participants can explain the agreed plan afterward, distinguishing adoption of the new process from its intended effect on understanding and continuity of care.

Apply it

A service aims to shorten response time by reducing initial interviews. Alongside response time, it monitors whether key perspectives are missed and whether cases require repeat clarification, checking whether faster access compromises assessment quality or creates additional work later.

Apply it

Overall consultation access appears timely, but stratified results show longer waits for people needing communication assistance. The service examines scheduling and accommodation arrangements, then tests a change directed at the identified barrier rather than assuming equal averages establish equitable access.

Apply it

A new referral process is followed by one week of faster responses. The service continues plotting response times, marks the implementation date and staffing changes, and examines whether the apparent improvement persists rather than declaring success from that week.

Apply it

One unit submits twice as many surrogate-related referrals as another. The service compares patient populations, consultation awareness, and applicable workflows before deciding whether targeted education, clearer policy, or improved access elsewhere best addresses the observed pattern in the organization.

Apply it

A service predicts that a revised referral form will reduce clarification calls. It tests the form in one setting, studies call frequency and omitted information, then revises confusing wording and plans another cycle before expanding the form across the organization.

Apply it

Repeated cases reveal that staff cannot locate existing advance directives. Instead of immediately rewriting the directive policy, the service investigates document access, tests a retrieval workflow, and brings evidence to the responsible committee about whether policy or resource changes remain necessary.